Thursday, October 21, 2010

ProPublica's Dollars for Docs Website

The non-profit media organization ProPublica just announced a new website/database called Dollars for Docs. It lists cash payments made to 17,000 U.S. doctors by seven large drug companies.

I’ve been browsing through the database and I have some thoughts about its strengths and weaknesses—and how it might be useful for patients.

First, here’s what these journalists did. Rather than waiting for the provisions of the Physician’s Payments Sunshine Act to take effect in 2013 (this will be a public website listing all payments to doctors from all drug companies), they decided to take matters into their own hands. Seven companies currently post physician payment data, in most cases because they were forced to as part of legal settlements. The problems is that these websites vary in quality and usability, and of course the data is split up among seven different sites.

ProPublica assignedtheirjournalists the daunting task of combining all the data into a single spreadsheet, which is titled “Dollars for Docs”.There are two ways you can use it: either by searching for a specific doctor, or by browsing the entire database.

For example, suppose you were interested in Dr. Lawrence Dubuske, the asthma expert who famously resigned from Harvard rather than having to abide by its new prohibition on promotional speaking. You would simply type in his name, click “search”, and you would find following entries. He received $25,500 from AstraZeneca in Q1-Q2 of 2010 for “speaker compensation;” $121,875 from GSK in Q2-Q4 2009 and another $72,400 in Q1-Q2 of 2010 for “speaking.”

Missing from the data, however, is any indication of what he was speaking about, who he was speaking to, or how many talks he had to give to make that kind of serious money. That’s not ProPublica’s fault, but rather the fault of the companies for not being specific enough. It would be crucial for me to know, for example, that my doctor made $100,000 for promoting the drug that I was just prescribed. The drug may be the best choice, or it may not be, but either way, I would feel deceived if I knew nothing about the doctor’sglaring conflict of interest. If I did know about this, and if I had enough chutzpah, I might then ask my doctor whether the money influenced his or her prescribing decision. (The inevitable answer: “Of course not, this money has absolutely no influence on my medical decisions.”)

There’s another way to use the Dollars for Docs database, although this is not spelled out on the website. If you want to browse for all the doctors in your city or state who are “on the take,” simply leave the “name” field blank, choose a state from the drop down menu, and click search. You’ll get a huge spreadsheet which is arranged alphabetically by last names of the doctors. By clicking on the various columns, you can sort the data by city, drug company, amount of money, or time period of the payments. This is a nice feature that is absent from most of the drug company databases.

I sorted all Massachusetts docs by “amount”and found that one doctor received only $17 from Eli Lilly in the first quarter of 2010. This payment was described as “Advising/Consulting and International Education Programs.” I’m not sure what that means, but I can’t imagine that Lilly got too much “advising” work out of this particular doctor.

Anyway, I scrolled down the chart looking for the more well-funded docs, and in doing so I quickly comprehended what is probably the most striking aspect of this database—the sheer enormity of it. Sure, I already knew from published surveys that well over 100,000 doctors receive cash from drug companies. But that number becomes much more tangible as you scroll through an endless list of doctors’ names, each associated with a specific dollar amount. The thought that runs through your mind is: “How have we allowed this to happen to our once proud profession?”

But occasionally I came across the name of a colleague who I knew was ethically scrupulous. In one case, for example, a friend was listed as having received $20,000 from a company for “consulting.” He is a former medical school classmate of mine, and I know he does serious epidemiological research, and that he is uninterested in working with drug companies. The point, again, is that without getting more specific information it’s hard to know what to make of these numbers.

Nonetheless, this database focuses on explicitly “promotional” activities, such as speaking and marketing consultation, and does not include payment for research studies. The vast majority of payments are for doctors who give “educational” talks to other doctors, presumably focusing on one of the drugs made by the funding company.

Is it ethically “bad” for your doctor to give these talks? That’s controversial. Clearly, there are some good apples who will express their honest opinions about which drugs are best without being influenced by the allure of money.

Nonetheless, doctors aren’t dumb, and they are acutely aware that they are serving two masters: the stockholders of the company and the doctors they are teaching. If they say bad things about the company’s drug, they’ll watch as the speaking invitations magically evaporate.

The true malfeasance here is in the aggregated effect. The companies are using these legions of doctors to artificially manipulate medical discourse. Any doctor who participates in the enterprise knows exactly how they are being used. You decide whether this is “immoral” or not.

9 comments:

Lots of familiar names, big bucks in my state. Am considering putting the widget on my practice Web site. One weakness I don't believe you mentioned: Seems to be restricted to physicians. I know of at least one ARNP who boast on the front page of her Web: "I am on the Speakers Panel for several large pharmaceutical companies and I consult both locally and on a national level with eminent clinical and research psychiatrists." (See http://alicelaurens.com/)

I hope they'll build an app for Android/iphone. Could liven up the doctor's lunch room.

I am so unspeakably glad that the public is finally getting a glimpse at the enormity of this problem.

For those in the medical profession who were concerned before last week about the public's declining trust in the profession, your problem just expanded exponentially.

If it weren't for all of the media exposure, most in the medical profession wouldn't even bat an eyelash about speakers' bureaus... they'd just keep speaking and depositing checks without giving it a second thought. Until the American public started to gain an understanding of the extent of your profession's behavior unbefitting of a fiduciary, it never even occurred to many of you that what you were/are doing was/is unethical and just plain wrong. Money talks. Mine walks... to someone else... the one who needs it more because his/her income isn't already being supplemented by pharma.

And re: Forrest's "preceptorship" - be forewarned... if I were your patient and you had the gall to even *ask* whether you could have your friendly sales rep sit in on my appointment, I would take 10 minutes of your time to explain several things to you:1. Why it is not OK2. Why you are an unethical human being and a sub-par professional (as evidenced by the fact that you think it's professional to let drug reps follow you around while you see patients)3. How you just permanently damaged our relationship in the most dramatic of ways4. How I will not be coming back to see you again5. How I will be sure to tell all of my other doctors about your gall6. How, since you did not examine me or address any of my medical problems while I was engaged in my monologue, I will not be paying you for today's visit... which shouldn't matter much since your friendly drug rep will pay you $1,000 for the privilege of watching me rip you a new one.

I don't want drug reps NEAR me. YOU shouldn't, either.

Now that everyone's behavior is going to be exposed, physicians should consider establishing practice-wide rules (like those established by Partners Healthcare). If I look at the list of doctors taking pharma speaking bribes and your practice partner appears on the list, I will think twice before seeing you, even if your specific name does not appear on the pharma bribe list. You just look bad if the guy down the hall from you is taking $40k per year from pharma. You. Look. Bad. And so does your entire practice.

Time for medicine to clean up its act. This sunshine is going to start hurting you if you are still taking speaking bribes, etc. Now that people know what's up, it should be fun trying to get new patients if there are non-bribe-taking alternatives to you in the area. I'm also betting you're going to be subjected to some uncomfortable inquiries from your current patients. So, have fun... while you're cashing your $10,000 pharma check. Have fun.

I'm a young psychiatrist, just finishing my training. In reviewing the list, I found that the highest-paid psychiatrist on the list (over $200,000) is a guy that I actually saw speak a few months ago. He was a great speaker, quite friendly, and very personable. In fact, we sat around and talked for about 15-20 minutes afterward, he gave me his card, and I've been thinking of contacting him for some advice and career guidance.

You can imagine my chagrin when I found out that this guy-- with whom I felt I had a personal connection-- probably has had similar interactions with hundreds of others.

Who knows, he might still be a great guy, and he might remember me and give me some great advice, but I can't help but feel duped. It just feels... well, gross.

(BTW, not that I'm an aficionado or anything, but isn't this sort of the same strategy that prostitutes, strippers, and phone-sex workers use with their clients???)

The Baltimore Sun paper this morning had a cover article about this, and I will link below, but, this quote from the Maryland Chapter of the AMA, Med Chi, from CEO Gene Ransom (ironic name, eh?) relates why I do not belong to medical organizations of late:

"Doctors take an oath to do no harm. Doctors, for a couple of hundred or a couple of thousand dollars, aren't going to risk their livelihoods or the lives of their patients."

What!?!? Is this leadership in my field these days? Am I the only doctor in Maryland who understands the concept of reciprocity, and knows it applies to doctors as well as the rest of the community we practice in?

Carl Elliott, a professor from the University of Minnesota Center for Bioethics is noted near the end of the article in this comment:

Elliott believes doctors will only stop accepting payments when they are held accountable for drugs that harm a patient, even if they never prescribed the drugs themselves.

That end is a bit disturbing though; If I never prescribe the new antipsychotics like Saphris and it turns out it grows a head on the patient's elbow, I am culpable? This is why the debate drags to any possible conclusion. First, docs are clueless in taking monies and thinking there are no consequences, then alleged Opinion Leaders in ethics and other areas trying to monitor this goes to the extreme of asking every doc be accountable, irregardless of their practice.

Well, at least the publication of this list may shame some. The article does mention two docs who made more than $180K and I will leave you the readers to read their rationalization to their pursuits.

To the anonymous Psychiatrist above who commented about interacting with a doc on the list, just remember this, if it is not an adage you believe prior: deeds, not words are what define us. Anyone accepting sizeable amounts of money from a pharmaceutical company that is still marketing a brand name drug, they will be promoting it in their office until proven otherwise. Otherwise, why would the pharma co be paying them onwards?

"I hope they'll build an app for Android/iphone. Could liven up the doctor's lunch room." I think DOX$RX$, the app, would also liven up many a waiting room!

Working with the CTSA/CTSI mechanisms from the community side, one is struck over and over again by the paucity of compensation and rigorous scrutiny/bureaucratic fuss for "civilians" participating in or supporting medical research. Maybe things are beginning to equalize?